My Cows or Yours?

Evidence for prevention
Prevention outweighs permissive policy for social benefit to the individual and to societyEd Jurith is currently temporarily occupying the desk of the USA’s ‘drug czar’ while President Bush decides whose name is ‘permanently’ painted on the door. Close to the end of his Atlantic Fellowship in England, Ed gave a talk in London to drug workers. He proposed and answered the rhetorical question: ‘What is the goal of US drug policy ? – A drug-free America’.

I watched his audience stiffen, then relax as he went on: ‘None of us expect 100% success, but as a goal to work towards, it’s not that bad.’

It is a mistake to assume that all the zealots are anti-drugs, any more than all the sacred cows are on one side of the fence. We all have our share of both.

The governing goal in our national strategy is to work towards the irreducible minimum of drug users. This is a common theme in both the current drugs strategy and its 1995 predecessor (its Appendix C has one of the most helpful definitions of the role of harm reduction).

When asked to identify the main tool to achieve this goal, most people choose ‘education’. But this is only one component – and by some accounts a deliberately ‘aimless’ one.1 You could, from this basis, educate a ‘drug fancier’ but the outcome at best would be an educated drug fancier.

Prevention differs from education by setting goals and boundaries and working within the social context. Prevention fosters a culture in which the desired situation is more likely to occur, more likely to be willingly chosen. The then Chief Executive, Council on Addiction for Northamptonshire, Robin Burgess, underscored this very even-handedly in Druglink, March/April 1996.2

Prevention must engage the whole society. This requires a substantial shift in attitude for several professions, given we are by nature symptom-focused and reactive. Suggesting, for example, that prevention should be limited to those ‘at risk’ is like limiting contraception to the pregnant.

Lofquist, in his classic text says: ‘We must get beyond the notion that prevention is merely stopping something happening, to a more positive approach that creates conditions which promote the well-being of people’.3

In simple terms to prevent we must be working ‘pre-event’. School or workplace drugs policies that only intervene when drug use is observed need extra front-end chapters to cover this.

What is the value of the law in prevention and health promotion? It spells out the boundaries and at least some of the consequences of breaching them. It also undoubtedly acts as a discouragement for some – hence the increase in use seen universally when laws are relaxed.

Intervention by the law, whether by Caution or Court, is credited by many in my experience with having decided them to avoid or turn away from drugs. In the USA the criminal justice system remains the top referral source for rehabilitation.

There is great potential for more constructive systems: for example, the National Drug Prevention Alliance advocates an extended caution applied to minor drugs offences, with a preventive aim (a working title might be ‘PreCaution’).

The principle is to offer a caution – or deferred sentence – with the condition of attendance at drug prevention training sessions, analogous to what happens now with drink driving cases. Failure to attend would constitute a breach and thus appearance in court. Costs could be limited by cooperation with the voluntary sector.

Law and criminal justice are parts of the interlocking structure of social agents that deal with positive and negative life issues to foster a healthy society. The problem with such structures is that removal of any part can lead to collapse. The ‘legal’ element may be easier to dislodge than many, starting with mislabelling it.

‘Prohibition’ conjures up images of a rejected policy and an American policy at that – very handy derogatory terms. The Australian Parliamentary Group for Drug Law Reform certainly believed so, to the extent that they deployed ‘ conscious manipulation of the language and debate ‘ – their words, not mine, ‘ labelling those who oppose drug law reform as ‘prohibitionists’ and those who seek it as ‘reformers’’.4

For equity, instead of prohibition I suggest ‘preventive policies’ – a less calculated term, less likely to promote a particular viewpoint. It also fairly balances the term for the opposite approach ‘permissive policies’. From this start point, let’s climb over the fence and vet some of the sacred cows in the ‘permissive’ herd:

Culling ?

‘US Prohibition equals UK drug policy’ – US tried to suppress what was until then a legal substance (alcohol), used by the majority of, and generally accepted by the public. The inverse of these parameters is true of our drug laws. No comparison.

‘US policy spectacularly unsuccessful’ – the US sustained drug prevention for 12 years from 1980–92, achieving a 60% drop, about 13 million fewer users.5 Things slipped thereafter as government and parents took their eyes off the ball, but prevalence is now declining again. This is despite ‘law-weakeners’ like George Soros investing huge amounts of money in permissive campaigning – he puts his personal input at $90 million (so far).6

‘Hundreds of thousands jailed in US for simple possession’ – sentencing for all offences, including drugs, has declined and is now at half the 1997 level. The average amount of cannabis per incarceration is 4,500 lbs. In 1998 alone 1.7 million pounds of cannabis were seized. Under 0.1% of those jailed are non-violent, first-time cannabis offenders.7

‘US incarceration policy is racist’ – demographic analysis belies this. In Northeast and Northwest regions sentencing black/white is equal, while in the Midwest whites do worse. Average sentences for the South are 1 month longer for blacks but, crucially, in this region all races are more likely to be convicted, and imprisoned for longer. This factor alone explains the differences.7

‘We are at surrender stage in the UK’ – despite the current World Health Organisation (WHO) European School Survey Project on Alcohol and other Drugs (EASAD) report, the white flag can stay in the locker for a long time yet. The UK Anti-Drugs Coordination Unit confirm that more than 80% of young people either never use at all (50%) or else give up after one or two tentative tries, a figure which has been growing for at least the last three years.

‘Just Say No doesn’t work’ – unsupported sloganeering certainly doesn’t work but the US programme of this name was much more. It was a comprehensive personal and social development process and one of the key factors in the prevention gains from 1980-92.

Undoubtedly some re-visit the slogan as a coded message implying prevention as a whole doesn’t work, but there is a growing body of evidence to rebut this slander. The work of experts such as Kumpfer8, Tobler9 and Benard10 relates to large numbers of successful initiatives.

But Joan Smith does have a point (Druglink Jan/Feb 2001 p.14). Latin America is certainly in a mess. Nowhere more so than Colombia under President Pastrana, a man who demonstrates his readiness to ‘milk the cow from both sides’ – sacred or not. Bellicose presidential anti-drug proclamations have been accompanied by awarding the drug-financed guerrilla forces a ‘police and army-free’ slice of Colombia the size of Switzerland.

Mexico is more encouraging. On a visit there recently George Bush said the time was past for Americans to blame Mexicans for a problem substantially derived from the demands of American youth. He said that priority should be given to ensure the effectiveness of prevention programmes, and that jailing first-time drug offenders: ‘may not be the best use of jail space, or the best way to free them from their disease.’

Danny Kushlik defines drug policy parameters (Druglink Jan/Feb 2001, p.20), but ends up with some dubious correlations. A more sound method is to look at the experience of countries that have tried to unravel their drug laws.11

Holland and Switzerland are glorified by some but there are enough negative reports, despite the predominantly libertarian media, to give cause for serious doubt.

Journalist and writer Larry Collins?12 is not impressed by the proposal to go Dutch. WHO and INCB experts have combined13 to condemn the Swiss experience as a questionable model – not to be followed by other countries.

Spain in the early 80s relaxed laws for cannabis, cocaine and heroin until parents shamed the government into a tougher stance. Italy in the late 80s rescinded lax heroin laws after record levels of addiction and death. Japan cut record abuse levels of amphetamines and heroin by applying firm laws with mandatory rehabilitation. In the distant past China found it necessary to apply stricter laws and education/rehabilitation to recover from damage by British-marketed opium.

Closer to home the ‘British experiment’ of heroin on prescription was revoked after it led to ‘leakage’ on to the street and record levels of youth addiction. Those European countries now approaching law relaxation may find themselves living through a previously-observed cycle – the three Rs: relax, repent, repeal.

In 1975 Alaska caved in to a well-orchestrated campaign for decriminalisation. The grounds for decriminalisation of cannabis were that this would not increase casual or chronic use as there was already lots of both about. It would not boost use of other drugs as cannabis as a gateway to other drug use is a myth. Crime would go down due to no possession charges and streets full of peaceful cannabis smokers.

More than a decade’s experience and observation convinced the Alaskan Supreme
Court that exactly the opposite had happened, and in 1990 the decriminalisation was rescinded.

Perhaps the most instructive example comes from Sweden.14 In the mid-50s Sweden found itself facing increased amphetamine use. Its natural instinct was to seek a liberal accommodation. Accordingly, the use of amphetamines was decriminalised while social/medical systems were put in place to accommodate the behaviour and minimise the harm.

Within 15 years the Swedes found amphetamine use had soared to enormous levels and with it social and medical costs. A new plan was introduce with the incremental introduction of firm laws plus mandatory treatment schemes. Today Sweden has prevalence levels a fraction of the rest of Europe.

Recent moves to relax the policy have been emphatically rejected, and Sweden stays with their preventive approach, which they characterise as ‘a vision expressing optimism and a positive view of humanity.’ The contrast between Sweden and, for example, Australia is, as researcher Dr Lucy Sullivan15 says ‘highly suggestive of which country has chosen the more effective approach’ (see table). (Full Drug Policy comparison article)

Sweden

Australia

Lifetime prevalence of drug use in 16-29 year olds (Sweden) and 14-25 year olds (Australia)

The culture in which decisions on life issues are taken is all-important, whatever the country.

In the case of youth and drug use in the UK, recent decades have seen many cultural developments: more drugs at lower real prices, a shift from community orientation to individualism, a search for rapid gratification, less guidance from (and faith in) religion, a pill for every ill, marching for rights but never for responsibilities. This comes with an increase in youth autonomy and spending power simultaneous with a decrease in traditional authority from parents, teachers and other civic/social agencies.

This may help to understand how the UK comes top of the European league for self-indulgence but it misses one important factor – what contribution have we, the relevant professionals in health, education and social fields, made to all this?

The answer is not flattering.16 There has been too much striving for acceptance by youth, too much selling out. We try to identify with youth and too often we over-identify. The result has been sizeable sections of youth who have scant respect for others, or for society’s boundaries. In effect they sign up for the (Rogerian) gospel of Values Clarification – a do-it-yourself morality kit.17 This is not education, it is abdication.

Steering the educationist juggernaut will be one of the biggest challenges to Keith Hellawell, our UK Anti-Drug Coordinator (many fail the driving test). It will require him to put some flesh on the bones of his rhetoric – however sincere.

Keith Hellawell is personally commited to minimising drug use, affirms that he is convinced of the significantly damaging effects of cannabis – physiological, social, emotional and intellectual. He says that he has ‘never been a just say no person, but is a say no for these reasons person’.

He rejects an educational approach that is relaxed about drug use, which replaces behaviour boundaries with harm reduction. But if prevention is ever to become more than a slogan he needs to put the Government’s money where his mouth is.

Prevention outweighs permissive policy every time in terms of social benefit to the individual and to society. And yet, when the sacred cows come home and when the relative strengths of our friends and our adversaries are weighed in the balance, we probably get the society we deserve.